Wounded Messenger

I pulled back the plunger, sucking lidocaine from the bottle into the syringe as I prepared to lance Jimmy's abscess. A voice in my head kept repeating, like a mean-spirited parrot, that I'd never done this procedure before--not even under supervision, and certainly not by myself...

I'd met Jimmy two months earlier. He'd come into our clinic with a fever, shortness of breath, a horrible cough, and a crumpled paper photocopy of a chest x-ray taken at another clinic. They'd diagnosed pneumonia and given him a course of antibiotics.

But now a month later, still coughing and drenched in sweat every night, he'd come to see us. He was pale, perspiring, exhausted and in pain. His respiratory rate and pulse were up; his temperature was 100.3.

When I listened to the bottom of his right lung, it sounded as though he were breathing underwater. I excused myself to discuss his case with my supervising physician. We agreed that we needed another chest x-ray as well as some basic labs.

This new film looked just as bad as the previous one. As I stared at it, I noticed thick white shapes where the airways entered the lungs.

"This doesn't look good," Dr. Herman said under his breath. "I'm worried about a mass. See here." He pointed to the white areas. "He needs a CT scan."

This meeting was the beginning of my journey with Jimmy. We treated his pneumonia with more antibiotics, painkillers and cough medicine. We ordered a CT scan; he was scared, but I convinced him to have it done.

As it turned out, he did have a lung mass. Then the biopsy report came back: small-cell carcinoma. Less than two percent of people survive five years after this diagnosis.

I felt an inner protest. Jimmy had quit smoking. He wasn't much older than me. It just wasn't fair.

When I saw Jimmy sitting in an examination room, waiting to hear his CT results, my mind went blank.

"Hi, Jimmy," I squeaked.

"So what's the news? Is it good or bad?" he asked.

I didn't have the guts to tell him, and I wasn't sure it was appropriate for a third-year medical student to do so.

"We'll be with you in a few minutes," I said, feeling like a coward as I went to find Dr Herman.

Jimmy reacted to the news with dead silence. Finally he asked, "So what do we do next?"

He started on chemotherapy. I saw him a number of times over the next few weeks. Once he told me angrily, "This may kill me, but not without a fight. It wasn't invited." He pulled a picture of his five-year-old daughter from his worn leather wallet and told me how much he wanted to be there to watch her grow up.

When he got upset, I'd try to calm him down. I usually ended our visits by saying, "Jimmy, stay strong," thinking that there was no way he could survive...

Now here was his tattooed back, naked in front of me. Again, I felt a sense of protest--he'd lost weight and lost his original teeth, and now he had an abscess under his skin. I tried to focus.

I'd noticed the tattoos in passing before, but now they were staring me in the face. On his right arm was a Maltese Cross with the words "Pecker Wood," and just below his neck was a woodpecker--symbols often associated with white supremacist groups. What kind of person was Jimmy outside of our clinic?

For a few moments, all I could see were these emblems of white supremacy.

I am Cherokee. About five years before meeting Jimmy, I'd spoken to a roomful of people at UC Berkeley about the civil rights and Black Power movements, and not long after that I'd introduced Ralph Nader to a crowd of 800 at UC Davis when he'd campaigned for President on a platform of immigrants' rights and other progressive causes. If Jimmy and I had met under different circumstances, I'd have given him a wide berth.

How would he have reacted to me?

I slipped the needle underneath Jimmy's skin near the abscess, to numb it. Then I plunged the scalpel blade into the abscess center. Usually the skin's resistance gives way and white pus oozes from the incision--but this time, nothing happened.

I dug deeper. Still nothing.

I was relieved that Jimmy couldn't see the sweat beads on my forehead and the dark circles under my armpits.

"I'm just taking some time," I said. "I want to make sure I get it all; I don't want it to give you any more problems."

"That's okay," Jimmy replied.

Then he asked, "Where do you plan on working when you're done with school?"

"I'm not sure yet," I said.

And then he said something unexpected: "I want you to know that I think whatever community you choose to work in will be very lucky to have you. You really care about your patients, and you don't judge them."

There I was, my scalpel buried in his back, uncertain of what I was doing--and Jimmy trusted me. I felt a surge of mixed emotions more intense than any I'd ever known.

I was elated that I'd achieved strong rapport with such a complicated patient; this was the first moment I truly felt like a healer. On the other hand, I wasn't sure I knew what I was doing. And in treating and comforting this particular patient--in fulfilling my duty as a student doctor--wasn't I betraying my other core values?

Just at that moment, the tension under my scalpel gave way, and pus oozed from Jimmy's incision.

About the author:

Jean Howell MD was a medical student in a nine-month rural physician elective when he wrote this. Therese Zink MD assisted in the writing of this piece.